Gastroenterologists as surgeons: what they need to know

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In this issue of Gastrointestinal Endoscopy, Jagannath et al present some of their pioneering work in the area of transgastric surgery, reporting upon the successful endoscopic transvisceral ligation of porcine fallopian tubes.¹ This follows on the heals of their initial reports of transgastric gastrojejunostomy and peritoneoscopy with liver biopsy. This work is exciting and innovative, opening a whole new arena of possibilities for minimally invasive therapy. Indeed, from other parts of the world, we hear anecdotal reports of such procedures as transgastric appendectomy having been performed in human subjects. The possibilities for future developments tantalize the imagination, yet the questions to be answered are legion.

In the past decade, minimally invasive approaches to therapy have developed in almost every specialty. In most cases, these have brought great patient benefit. Some have developed through careful scientific study, while others have emerged from mere ideas. The use of an intragastric balloon for the treatment of morbid obesity was prophetic and ahead of its time. Initial clinical experience was marred by complications that may have been avoided with careful preclinical trials. Though laparoscopic cholecystectomy has clearly become the standard for excision of the gallbladder, its explosive development was driven more by market forces than by science.

Endoscopic transvisceral surgery presents wonderful possibilities for benefiting patients. However, before its clinical implementation, many questions will need to be answered. Some of these include:

Clearly, these are fertile areas for research, and many of these questions will need to be addressed before adoption of these methods as clinical standards.

Another tantalizing question is who should perform these procedures. Clearly, gastroenterologists expert in flexible endoscopy have taken the lead. However, as these individuals become expert in these new methods, they will have to address clinical problems now faced by surgeons. For example, they will be faced with such problems as bleeding, anastomotic leakage, bowel obstruction, intra-abdominal sepsis, and ileus, to name a few. And, when they learn to deal with these, and they will, will they any longer be gastroenterologists or endoscopic surgeons?

In many areas of medicine, we are beginning to see the blurring of lines across specialties. For example, stent placement for carotid stenosis is being performed by vascular surgeons, interventional radiologists, cardiologists, and neurologists. These individuals are coming to the arena from differing approaches but all must, in the end, perform the procedures in the same manner, with the same results. Similar issues occur in other clinical areas. Eventually, what is clear is that specialty lines will change and those performing these transvisceral procedures will require training in both surgery and gastroenterology to best serve their patients. As these methods evolve, it will be important for surgeons and gastroenterologists to work together to refine the techniques and to develop the scientific foundation upon which these important developments will be based.

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Reference 

1. Jagannath SB, Kantsevoy SV, Vaughn CA, Chung SSC, Cotton PB, Gostout CJ, et al. Peroral transgastric endoscopic ligation of fallopian tubes with long-term survival in a porcine model. Gastrointest Endosc. 2005;61:449–453
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